Provider Demographics
NPI:1346929924
Name:BROOKSHER, KELLIE LANE (NP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:LANE
Last Name:BROOKSHER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 W 25TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6924
Mailing Address - Country:US
Mailing Address - Phone:928-344-6263
Mailing Address - Fax:928-317-0544
Practice Address - Street 1:1951 W 25TH ST STE D
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6924
Practice Address - Country:US
Practice Address - Phone:928-344-6263
Practice Address - Fax:928-317-0544
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRNP294682363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health